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Post cardiac arrest care 2015

2015 ACLS Post Cardiac Care

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Post cardiac arrest care 2015

  1. 1. Post–Cardiac Arrest Care Circulation. 2015;132[suppl 1]:S465–S482.
  3. 3. Acute Cardiovascular Interventions  Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I)  Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa)  Coronary angiography is reasonable in post–cardiac arrest patients for whom coronary angiography is indicated regardless of whether the patient is comatose or awake (Class IIa)
  4. 4. Hemodynamic Goals Avoiding and immediately correcting hypotension (SBP less than 90 mmHg, MAP less than 65 mmHg) during post- resuscitation care may be reasonable (Class IIb)
  6. 6. Induced Hypothermia We recommend that comatose adult patients with ROSC after cardiac arrest have TTM (Class I for VF/pVT OHCA; non- VF/pVT (ie, “non-shockable”) and IHCA) We recommend selecting and maintaining a constant temperature between 32oC and 36oC during TTM (Class I) It is reasonable that TTM be maintained for at least 24 hours after achieving target temperature (Class IIa).
  7. 7. Avoidance of Hyperthermia It may be reasonable to actively prevent fever in comatose patients after TTM (Class IIb)
  9. 9. Ventilation Maintaining the PaCO2 within a normal physiological range, taking into account any temperature correction, may be reasonable (Class IIb).
  10. 10. Oxygenation  To avoid hypoxia in adults with ROSC after cardiac arrest, it is reasonable to use the highest available oxygen concentration until the arterial oxyhemoglobin saturation or the partial pressure of arterial oxygen can be measured (Class IIa).  When resources are available to titrate the FiO2 and to monitor oxyhemoglobin saturation, it is reasonable to decrease the FiO2 when oxyhemoglobin saturation is 100%, provided the oxyhemoglobin saturation can be maintained at 94% or greater (Class IIa).
  12. 12. Timing of Outcome Prediction  The earliest time for prognostication using clinical examination in patients treated with TTM, where sedation or paralysis could be a confounder, may be 72 hours after return to normothermia (Class IIb)  We recommend the earliest time to prognosticate a poor neurologic outcome using clinical examination in patients not treated with TTM is 72 hours after cardiac arrest (Class I).  This time until prognostication can be even longer than 72 hours after cardiac arrest if the residual effect of sedation or paralysis confounds the clinical examination (Class IIa)
  13. 13. Clinical Findings That Predict Poor Neurologic Outcome  Absence of pupillary reflex to light at 72 hours or more after cardiac arrest  Presence of status myoclonus during the first 72 hours after cardiac arrest  Absence of the N20 somatosensory evoked potential cortical wave 24 to 72 hours after cardiac arrest or after rewarming  Presence of a marked reduction of the gray-white ratio on brain CT obtained within 2 hours after cardiac arrest  Extensive restriction of diffusion on brain MRI at 2 to 6 days after cardiac arrest  Persistent absence of EEG reactivity to external stimuli at 72 hours after cardiac arrest  Persistent burst suppression or intractable status epilepticus on EEG after rewarming
  14. 14. PCAC Ventilation Hemodynamics CardiovascularNeurological Metabolic
  16. 16. Capnography Rationale: Confirm secure airway and titrate ventilation Endotracheal tube when possible for comatose patients Petco2∼35–40 mmHg Paco2∼40–45 mmHg
  17. 17. Pulse Oximetry/ABG Rationale: Maintain adequate oxygenation and minimize FiO2 SpO2 ≥94% PaO2∼100 mmHg Reduce FiO2 as tolerated to keep SpO2 or SaO2 ≥94%
  19. 19. Frequent BP Monitoring/A-line Rationale: Maintain perfusion and prevent recurrent hypotension MAP ≥65 mmHg or SBP ≥90 mmHg
  20. 20. Treat Hypotension Rationale: Maintain perfusion Fluid bolus if tolerated Dopamine 5–10 mcg/kg per min Norepinephrine 0.1–0.5 mcg/kg per min Epinephrine 0.1–0.5 mcg/kg per min
  22. 22. 12-lead ECG/Troponin Rationale: Detect ACS/STEMI; Assess QT interval
  23. 23. Treat ACS Aspirin/heparin Transfer to acute coronary treatment center Consider emergent PCI or fibrinolysis
  25. 25. EEG Monitoring If Comatose Rationale: Exclude seizures Anti-convulsants if seizing
  26. 26. Core Temperature Measurement If Comatose Rationale: Minimize brain injury and improve outcome Prevent hyperpyrexia >37.7°C Surface or endovascular cooling for 32°C– 34°C × 24 hours After 24 hours, slow re-warming 0.25°C/hr
  27. 27. METABOLIC
  28. 28. Serial Lactate Rationale: Confirm adequate perfusion
  29. 29. Serum Potassium Rationale: Avoid hypokalemia which promotes arrhythmias Replace to maintain K >3.5 mEq/L
  30. 30. Serum Glucose Rationale: Detect hyperglycemia and hypoglycemia Treat hypoglycemia (<80 mg/dL) with dextrose Treat hyperglycemia to target glucose 144–180 mg/dL Local insulin protocols